dropoffForm We are happy to announce that on Monday, April 4th, we will start welcoming all clients back into the building with your pets! We will also continue to offer services curbside, if that suits you best.A mask is not required, but still strongly recommended per L.A. County Department of Public Health. IMPORTANT: If you are experiencing any flu, cold or COVID like symptoms- we ask that you refrain from coming inside the clinic.Please be sure to enter all information below and click “Submit” for the form to be emailed to us PRIOR to your appointment. Required information is marked with an asterisk* and form cannot be submitted unless all required information is entered.Thank you to all the clients that have continued to let us care for your fur babies during these times, we appreciate your flexibility and understanding. Client Name* Pet's Name* Appointment Date* MM slash DD slash YYYY Appointment Time* Hours : Minutes AM PM Name of Person Bringing Pet* Preferred Email Address* Preferred Phone Number*QUESTIONS REGARDING COVID19HiddenHave you or anyone in your household traveled out-of-state or by plane within the past 14 days? Yes No HiddenHave you or anyone in your household experienced any cold or flu-like symptoms within the last 10 days? This includes the following symptoms: fever (at or over 100.4 F), chills, cough, shortness of breath/difficulty breathing, or new loss of taste or smell. Yes No HiddenHave you or anyone in your household tested positive for COVID-19, or been exposed to anyone that has tested positive for COVID-19 within the last 10 days? Yes No HiddenAre you currently on a quarantine or isolation order? Yes No HiddenAre you fully-vaccinated against COVID19? Yes No Reason for Visit: (check all that apply)EXAM: Annual Wellness Illness/Injury Recheck For Surgery For Dental Medication Refill OTHER SERVICES: Bandage Change Radiographs Labwork Ultrasound Other Please explain furtherAre there any concerns for:(check all that apply) Eating habits Drinking habits Vomiting Diarrhea Coughing Sneezing Itching/scratching Bad breath Difficulty rising Skin masses/leisons Lethargic Excessive sleeping Scooting Urination issues Weight gain or loss Shaking head Behavioral problems Other Eating habits - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Drinking habits - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Vomiting - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Diarrhea - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Coughing - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Sneezing - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) How itchy is your pet on a scale of 1-10?(1 = not at all, 10 = up all night itching) 1 2 3 4 5 6 7 8 9 10 Where is your pet scratching/itching? Bad breath - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Difficulty rising - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Skin masses/leisons - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Lethargic - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Excessive sleeping - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Scooting - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Urination issues - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Weight gain or loss - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Shaking head - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Behavioral problems - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Other - please explain further(such as: When did the problem start? Any inciting event? Has it improved, worsened or remained the same?) Is your pet on any flea control?* Yes No If yes, what is the name of the flea control and when was it last given? Is your pet on any heartworm prevention?* Yes No If yes, what is the name of the heartworm prevention and when was it last given? Does your pet have any allergies to food or medications?* Yes No If yes, please list the food and/or medications. CURRENT MEDICATIONSMedication Name Amount Given Frequency Last Given Next Due Medication Name Amount Given Frequency Last Given Next Due Medication Name Amount Given Frequency Last Given Next Due Medication Name Amount Given Frequency Last Given Next Due If your pet is on any medications, do you need a refill? Yes No If yes, which medications? Does your pet have any history of vaccine reactions in the past?* Yes No If yes, explain: Does your pet have any chronic medical conditions? Or previous surgeries?* Yes No If yes, explain: Is the patient indoor, outdoor, or both?* Indoor Outdoor Both What are you feeding your pet? (Brand of food/, wet/dry, frequency/amount given)* Would you like your pet to receive any of the following routine services today?(check all that apply) Update vaccines Heartworm test Fecal test Microchip Deworming Ear cleaning Nail trim Flea medication Anal gland expression Any additional comments/concerns? EXAM/TREATMENT PLAN: I understand that the veterinarian will first examine my pet and call me to get authorization of an itemized treatment plan PRIOR to moving forward with any procedures or treatments on my pet. I acknowledge that I am the owner or appointed caregiver and will be giving verbal authorization for treatments by phone.Client initials:* EAR CLEANING/MEDICATIONS: While it is exceedingly rare to have any form of complication(s) with the recommended treatment(s), I understand that there is an inherent risk to using any medication and/or ear cleaner and that these products do have the potential to cause temporary or permanent hearing loss. I give my consent to proceed with ear cleaning and/or medication if indicated after examination.Client initials:* SEDATION/ANESTHESIA: I understand that it can pose a risk to my pet, regardless of health status. I give permission to have anesthesia or sedation administered and take reasonable measures in treating my pet in the event of unforeseen circumstances.** If sedation/anesthesia is deemed necessary in order to examine or treat your pet, you will be contacted PRIOR so that you are aware of the need before it is administered.Client initials:* URGENT CARE: If urgent care becomes necessary for the health of my pet, I understand that the staff will make every effort to contact me as time allows. If I cannot be contacted, I authorize any and all treatments as determined by the veterinarian and accept all charges that are incurred as a result of such action.Client initials:* I understand that payment must be made if full at the time of pick up, and I am aware that Western Veterinary Group, and DOES accept cash, credit cards, Care Credit, and ScratchPay, and DOES NOT accept personal checks.
